ABSTRACTBackground: Discharge against medical advice (DAMA) has emerged as a pervasive problem in hospitals. Since the incidence and reasons for DAMA varies from one society to another and among clinical conditions, this study was undertaken to evaluate the occurrence of DAMA among Orthopaedic trauma patients in a teaching hospital with a view to identifying appropriate preventive strategies.Methodology: A prospective cohort study of Orthopaedic trauma patients who presented at a teaching hospital over a six-month period and indicated their desire to leave the hospital against medical advice. The patients were interviewed after obtaining informed consent; information obtained included sociodemographics and reasons for discharge against medical advice which were entered into a proforma. For those who indicated intention to go to the traditional bone setters for further treatment, the reasons for such a decision were obtained. Data was analysed using SPSS version 16.Results: A total of 488 orthopaedic trauma patients presented at the Accident and Emergency unit of the hospital during the study period. Twenty nine (5.9%) of the patients, discharged themselves against medical advice. Male to female ratio was 3.8:1.0 with median age of 30 years. Main reasons for DAMA were: going to the traditional bone setter – 11 (37.9%); not satisfied with planned treatment – 10 (34.5%); no one to take care of me/children while on admission – 6 (20.7%), financial constraints – 2 (6.9%). Of the 11 patients who left hospital to go to the traditional bone setter (TBS), 7 (63.6%) indicated that they had more faith in the TBS method of treating injuries.Conclusion: Discharge against medical advice is common among orthopaedic trauma patients in our hospital. Intensification of the campaign to purge the society of misplaced belief in the supernatural prowess of the TBS in treatment of orthopaedic trauma injuries and improvement of patient-doctor communication are advocated as preventive strategies.

INTRODUCTION
Discharge against medical advice, defined as patient discharge from the hospital or health care facility before the treating physician recommends discharge, has emerged as a pervasive problem in hospitals.[1,2] Such encounters often lead to frustration and resentment on the part of clinicians and poor outcomes and worsening health for patients. 1 Orthopaedic trauma patients often have to beadmitted for treatment especially in societies where home care is inadequate or nonexistent.
This way, treatment can be effectively monitored to enhance outcome. Admission can be difficult for patients and their relations as a result of concerns about handling of domestic, religious and economic issues.[1,2,3] This often results in dislocations of the family, and social activities of the patient may be disrupted. It is therefore not unusual for patients to discharge themselves from hospital against medical advice. The incidence of discharge against medical advice (DAMA) ranges from 0.2% to 2.2% of hospital admissions in developed societies.[1,2,3] A rate as high as 6% in an area where alcohol and drug abuse is a social problem has been reported.[4] Even though discharge against medical advice is found to be influenced by a number of factors including patient’s medical condition as well as the availability or otherwise of health insurance[,1,4,5] it has been reported to be more common in alcoholics and drug addicts as well as mentally and psychologically challenged patients.4 DAMA has been found to be associated with higher morbidity, mortality and readmission rates.1 The most important void in the literature on discharges against medical advice is the lack of understanding of why patients choose to leave. Identifying these reasons is essential to the design of any preventive intervention. Patients need to be interviewed to find out what motivates them to leave hospital against medical advice.[5] Since the incidence and reasons for DAMA varies from one society to another and among clinical conditions, this study was undertaken to evaluate the occurrence of DAMA among Orthopaedic trauma patients in the University of Uyo Teaching Hospital. It is hoped that the findings of this study would engender the formulation and implementation of measures to reduce the incidence of DAMA thereby allowing effective treatment of orthopaedic trauma patients.

METHODOLOGY
This was a prospective study of Orthopaedic trauma patients who presented at the Accident and Emergency unit of the University of Uyo Teaching Hospital, from 1st November 2008 to 30th April 2009. Patients who indicated desire to leave hospital against medical advice were interviewed by the surgical resident on duty in casualty after obtaining informed consent. Information obtained included their socio-demographic data, injury sustained, duration of admission, reason for leaving, alternative place of treatment following DAMA. For those who indicated their intention to go to the traditional bone setters for further treatment, the reason for such a decision was obtained. All the patients were appropriately counselled on the nature of their injuries and the planned treatment discussed with them.
The total number of surgical emergency and orthopaedic trauma admissions was obtained monthly over the study period. Data obtained was analysed using the Statistical Package for Social Sciences (SPSS) computer software version 16. Fisher exact test was used to test for statistical significance; A p value of p<0.05 was considered statistically significant.

RESULTS
A total of 1,578 emergencies presented at the Accident and Emergency unit of the hospital during the study period, out of which 488 were orthopaedic trauma patients constituting 30.9%.
Twenty nine (5.9%) of the orthopaedic trauma patients discharged themselves against medical advice. The majority (79.3%) of the patients were males, with male to female ratio of 3.8:1.0. Over seventy percent of the patients were aged 20 to 39 years, median age was 30 years.
Most (89.7%) of the patients were educated. The treatment of 75.8% of the patients was sponsored by a third party (family member, friend, assailant). The mean duration of admission in the accident and emergency unit before discharge against medical advice was 3.52 days (±SD 2.46). None of these patients accepted admission into the wards. Reasons for DAMA were going to the traditional bone setter – 11 (37.9%), not satisfied with planned treatment – 10 (34.5%), no one to take care of me/children while on admission – 6 (20.7%), financial constraints – 2 (6.9%), poor attitude of hospital staff –1 (3.4%) and delay in administration of treatment – 1 (3.4%). Of the 11 patients wholeft hospital to go to the traditional bone setter, 7 (63.6%) indicated that they had more faith in traditional bone setters than orthodox medical practice while perceived lower charges was the reason for their patronage in 8.2% of cases. Fracture was the commonest injury sustained constituting 65.5% of cases while the lower limbs were most frequently injured (69.0%).
There was a statistically significant correlation between patient age of more than 25years and occurrence of fracture with the patronage of traditional bone setters (p=0.048 and 0.044 respectively).

DISCUSSION
Patients have a right to decide to leave the hospital. This was reiterated by Steventack, a member of the board of the American Medical Association, when he said “Medical decisions are a partnership between the patient and the doctor, but the patient is nearly always the final decision maker”.[1] However, this decision if taken against medical advice is not without consequences. Patients who leave the hospital against doctor’s orders have been reported to be at a higher risk of adverse health outcomes and have increased hospital readmission rates, compared with patients who follow doctors’ advice.[1]
Even though the DAMA rate of 5.9% in this study is slightly higher than rates obtained in more developed societies [1,2,5], it is lower than rates found in similar studies in Nigeria.[6,7] This may not be unconnected with the relatively high literacy level of the patients in the index study (89.7%). The preponderance of males (79.3%) leaving hospital against medical advice in this study is consistent with findings of other studies.[1,3] In our society, many orthopaedic trauma patients are known to patronise traditional bone setters (TBS) and various reasons have been adduced for this. In this series, 34.9% of the patients who left the hospital against medical advice resorted to treatment by the TBS. Most of these patients (63.6%) gave having faith in the method of treatment by the TBS as the most common reason for their patronage. This may be related to some cultural beliefs that the TBS possess certain supernatural powers that confer them with the ability to easily treat musculoskeletal injuries.[6,8] Fractures and age of patient above 25years were found to significantly predict the patronage of TBS by orthopaedic trauma patients in this study (p=0.044 and 0.048 respectively). Other studies have shown that many orthopaedic trauma patients who patronise the TBS usually eventually return to orthodox care as a result of complications.[9,10,11] That 34.5% of patients who left against medical advice in this study were dissatisfied with the planned treatment is significant. This brings to the fore the need to improve facilities in our hospital for the care of orthopaedic trauma patients. Also critical is the need to improve patient-doctor communication especially as it relates to the issue of obtaining informed consent.[12] The finding that most of the patients left the hospital within 5 days of admission is consistent with results of another study in Nigeria.[6] This suggests that these patients only came to the hospital for stabilisation (First Aid) before leaving to their preferred place of treatment.

CONCLUSION
The main reasons for leaving hospital against medical advice by orthopaedic trauma patients in this study included their desire to patronise the TBS for further treatment and dissatisfaction with the planned treatment in hospital. The patronage of TBS after the patients have left hospital against medical advice were related to the male sex, fracture, age more than 25years and injury involving the lower limbs. Despite the relatively small study population, the findings are critical and of appreciable importance in designing measures to keep orthopaedic trauma patients in hospital with a view to ensuring adequate treatment of their injuries. Intensification of the campaign, by way of education, to purge the society of the misplaced belief in the supernatural prowess of the TBS in the treatment of orthopaedic trauma injuries as well as consistent improvement of patient-doctor communication are advocated as preventive strategies. The latter will involve in-depth and continuous training of medical personnel in medical communication skills.